Pathology Service / DCN / HIS-P-003-1.2
Department of Histopathology / Page / 1 of 9
Date of Issue / 28/03/2013
Histopathology Service User Handbook
VERSION No / Version 1.2
DATE OF ISSUE
/ 28/03/2013REVIEW INTERVAL / 24 months
AUTHORISED BY / Dr J Armstrong
AUTHOR / A Bryant
COPY / One
LOCATION OF COPIES /
- General Procedures Folder
- Q-Pulse™
Document review history
Review date / Reviewed by / Signature
Contents
Contents...... 2
0Document Control...... 3
1General Information...... 3
2Contact Details...... 4
3Service Availability...... 4
4Laboratory Location...... 4
5Results...... 5
6Clinical/Technical Advice...... 5
7Tests...... 5
8Referred Tests...... 5
8.1HER2 Testing
8.2Flow Cytometry
9Specimen Collection / Transport...... 6
9.1Specimen Containers
9.2Specimen acceptance/rejection
9.3Products of Conception
9.4Health & Safety
10Quality Management...... 7
11Histology Tests...... 8
0DOCUMENT CONTROL
This handbook is subject to the document control procedures used in the Pathology directorate. As this version is controlled electronically, any printed copies or locally-saved electronic copies will no longer be subject to the document control procedures. Please ensure that any reference is made to the current active version of the document.
1General Information
The Histology Service is provided by the laboratory at the Great Western Hospital, Swindon. We provide an analytical and interpretative service on a wide-range of clinical specimens. Since we receive over 19,500 specimens each year, our efficiency depends to a large extent on your cooperation. Your compliance with a few rules concerning safety, specimen identification and transport will greatly help us to deliver the service you need. We hope that this handbook outlines all the information you require to use our service. However, please feel free to contact us to discuss any problems or issues you may have. Any comments or suggestions about the User Handbook should be addressed to the Laboratory Manager.
We aim to be a model of excellence in the delivery of a clinical pathology service. In order to achieve this, we are committed to the following:
- Service user involvement
- Good professional practice & evidence-based practice
- Efficient utilization of resources
- Valuing our staff in order to realize their full potential
- Commitment to the health, safety and welfare of our patients, staff and visitors
- Keeping a safe environment in compliance with current environmental legislation
- Working as teams and partnerships
- Continuous improvement
2Contact Details
Histology / Consultant Pathologist / Dr Lawrence John / 4282Histology / Consultant Pathologist / Head of Department / Dr Janette Armstrong / 4279
Histology / Consultant Pathologist / Dr Darko Lazic / 4280
Hsitology / Consultant Pathologist / Dr Sam Banerjee / 4797
Histology / Laboratory Manager / Mrs Alyson Bryant / 4277
Cellular Pathology / Secretaries / Ext 4999, 5000, 5002
3Service Availability
The laboratoryis open for receipt of specimens from 0830 to 1700 between Monday and Friday. All specimens must be delivered to Pathology Reception. Any specimens delivered to Pathology reception out-of-hours must be in formalin otherwise diagnostic interpretation may be affected.
4Laboratory Location
The laboratory is part of the Directorate of Pathology, within the Great Western Hospitals NHS Foundation Trust. The department is sited on the fourth floor of the main hospital building (see diagram). The postal address is as follows:
Department of Histology
Great Western Hospitals NHSFoundation Trust
The GreatWesternHospital
Marlborough Road
Swindon
Wiltshire
SN3 6BB
5Results
Please note that we need to establish the caller’s identity before giving results over the telephone. We are unable to give results directly to patients or their relatives.
Authorised results are available on the Medway system, ICE, and the Winpath Ward Enquiry system. Results may also be obtained by telephoning extension 4999, 5000 or 5002 (direct dial 01793 604999 / 605000 / 605002).
In general, results are not available until they have been authorised. In exceptional circumstances, preliminary results may be available direct from the Consultant Pathologists. However, please bear in mind that this may delay the testing of other samples.
6Clinical/TeCHnical Advice
For clinical advice on the interpretation of results, please contact the relevant Consultant Pathologist. Laboratory and office staff are not authorised to provide advice on the interpretation of results.
For advice on technical aspects of histology testing, contact the Laboratory manager or Biomedical Scientists in the laboratory.
7Tests
A list of services provided by the Histology laboratory is detailed in Section 11. Routine Histopathology only should be requested at the time of submitting the specimen to the laboratory. The need for additional tests is only usually determined by the Consultant Pathologists.
8Referred Tests
We only refer work to laboratories which have an accredited quality management system. The accreditation status and turnaround times of these laboratories are regularly reviewed.
The following services may be obtained via the Histology laboratory:
8.1Molecular Testing
When a molecular test (Her2, KRAS, EGFR, etc) is required, this must be discussed with, and authorised by a consultant histopathologist. Discussion usually takes place at an MDT, and requests are submitted to the department via the email address, copying in the laboratory manager. The Consultant will then choose the most appropriate block from the case to be referred for testing.
8.2Flow Cytometry
Lymph node biopsies for which lymphoma is suspected should be sent fresh to the laboratory. The laboratory must be contacted prior to delivery of these samples, and Dr Lazic should be contacted for any clinical advice. Samples cannot be accepted on Fridays as the referral lab will not accept samples on weekends. Any samples where TB is suspected must be sent in formalin and flow cytometry will not be carried out. Samples of the lymphoma cases are sent to a referral laboratory for flow cytometry testing.
8.3Network MDTs
Some cases will require referral to Network MDTs following discussion at a local MDT. Requests for cases to be sent to a Network MDT must be made by email to the email address, copying in the laboratory manager. The request must be sent as early as possible in order to allow the laboratory time to process the request, and must detail what is to be sent (i.e. blocks and/or slides). Blocks AND slides will always be sent to the Lymphoma Network MDT.
8.4Ophthalmic Specimens
Ophthalmic specimens are booked into the GWH Histology IT system but are sent to the National Specialist Ophthalmic Pathology Service (NSOPS) at University College London for processing and reporting. The report is uploaded to Winpath from NSOPS’ web portal.
8.5Cases sent for external reporting
A proportion of our cases are sent to an external provider for reporting due to limited capacity in-house. These will usually be non-urgent cases, and are dissected and processed at GWH. The slides are sent away for reporting, and the report returned by email to for uploading to Winpath. There may be occasions where urgent cases are sent away for reporting when consultant capacity in-house is reduced. The decision to send urgent cases will be made by the laboratory manager and/or lead consultant.
9Specimen Collection / Transport
9.1Specimen Containers
Specimens must be submitted in 10% formalin unless prior arrangement has been made with a member of laboratory staff. The volume should be at least 10 times the volume of the specimen. All specimens must be placed in appropriate sized containers and sufficient formalin should be added to cover them. Any specimens being delivered after 5pm MUST be in an appropriate container with an adequate volume of formalin as they will not be handled by laboratory staff until the following morning (or Monday morning if delivered after 5pm on Friday). If specimens are in an inadequate volume of formalin they will undergo bacterial autolysis and the quality of diagnostic interpretation able to be carried out will be affected.
Specimen containers can be obtained from the Directorate Support Administrator for Diagnostics and Outpatients (extension 5188).
9.2Specimen acceptance/rejection
All specimens must be accompanied by a complete and legible Histology Specimen Request form. A MINIMUM of three matching unique patient identifiers are required on samples and request forms. Where multiple pots areaccompanied by a single form, each pot must be detailed on the request form, and the unique patient identifiers must match on all pots and the request form. See table below for information which should appear on completed requestforms and specimen containers. Unique Patient Identifiers are listed in bold.
REQUEST FORM
/SPECIMEN
a) Surnameb) First name
c) Date of Birth
d) Hospital Number (if available)
e) NHS Number
f) Patients address
g) Ward
j) Patients Gender
i) Requesting Doctor / GP’s Name
j) Clinical Details
k) Type of specimen and, where
appropriate, anatomical site of
origin
l) The test required must be clearly
marked
m) Date and Time of Sampling.
n)Requesting Doctor’s Bleep number / a) Surname.
b) First name.
c) Date of Birth.
d) Hospital Number (if available).
e) Ward.
f) Date and time sample taken.
Specimens received unlabelled (specimen pot and/or request form), where there are not 3 matching unique patient identifiers, or where there is insufficient clinical information will be rejected by the department.
If a specimen is received leaking, it is still accepted into the department. If the form has been contaminated with formalin and/or body fluids, the source department will be contacted and requested to provide a new form.
9.3Products of Conception
Specimens of Products of Conception (POC) that require cremation after processing need to be accompanied by a cremation form. The legislation surrounding this is very stringent, and the form needs to be completed with care. Incomplete cremation forms will be returned to source to be completed while the specimen is being processed. POCs are still subject to the acceptance/rejection criteria detailed in point 8.2.
9.4Health & Safety
Samples thought to constitute a risk to staff because of inadequate packing/fixation or warning may be rejected.
Formalin is harmful by inhalation, in contact with the skin/eyes, and if swallowed. It shows limited evidence of a carcinogenic effect. Spillages should be absorbed using commercially available spillage granules or spillage kits. Out-of-date formalin should be brought to the histology department for disposal. For further advice/material safety data sheets etc, contact the laboratory manager.
10Quality Management
The Pathology Service is committed to maintaining accreditation for its quality management system. Accreditation is undertaken by Clinical Pathology Accreditation (UK) Ltd, an independent external organisation.
Details of our accreditation, together with performance data, are available from the Laboratory Manager. As part of our quality management system we routinely monitor certain performance indicators. These include External Quality Assurance (EQA) scores and specimen Turnaround Times (TAT). Any failures/poor performances in these indicators are investigated.
In order to help us improve our service, we may ask you to complete a questionnaire. We greatly value the information obtained from these surveys, and we would like to thank you in anticipation of your assistance in completing the questionnaires.
User Handbook - Histology
Great Western Hospitals NHS Foundation Trust Pathology Service / DCN / HIS-P-003-1.2Department of Cellular Pathology / Page / 1 of 9
Date of Issue
11Histology Tests
Investigation / Test / Sample / Container / TAT / Limitations / Out-of-Hours / Rejection CriteriaRoutine Histology / Histopathology Investigation / Various / Container with 10% formalin / 6 weeks / none / no / Insufficient / inappropriate clinical/patient data
(see point 9.2)
Urgent Histology / Histopathology Investigation / Various / Container with 10% formalin / 7 days / By request only / no / Insufficient / inappropriate clinical/patient data
(see point 9.2)
User Handbook - Histology